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P ROGNOSIS 1 Both mother and fetus are at higher risk compared with cephalic presentation. Maternal morbidity and mortality is increased because of greater frequency of operative delivery especially in emergency cesarean deliveries.

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P ROGNOSIS 2 Perinatal mortality and morbidity: prognosis of the fetus is considerably worse than the vertex presentation Major Contributers: preterm delivery, congenital anomaly and birth trauma Outcomes: Due to careful assesment before vaginal delivery and increased cesarean, bad outcomes are decreased from %9 to %3 from to

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RECOMMENDATION FOR DELIVRERY Up to %87 cesarean Frank breech term with E.F.W= Grams and adequate pelvis and flexed head is good candida for vaginal delivery

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R ECOMMENDATION FOR CESAREAN Large fetus Any degree of contraction or unfavarable shape of the pelvis Hyperextension of fetal head Indicated delivery Uterine dysfunction Incomplete or footling breech An apparently healthy and viable fetus in mother with indicated delivery or in active labor Sever I.U.G.R Previous prenatal death or children suffering from birth trauma Request of T.L Lack of experienced operator

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L ABOR MANAGEMENT 1 During labor both mother and fetus are at considerably increased risk compared with cephalic presntation so rapid evaluation should be made to establish the status of membranes,F.H.R,uterine contractions, and cervical condition A venous catheter is inserted and infusion begun as soon as possible

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Route of delivery may have taken place before admission based on the type of breech,flexion or extention of head,fetal size,quality of contractions,type and size of maternal pelvis and preferences of the informed parents. Sonography for fetal anomaly L ABOR MANAGEMENT 2

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Radiography is necessary for vaginal delivery Guidelines for monitoring the high risk fetus are applied (one-on – one nursing,fetal monitoring and physician must readily available) Risk of cord prolapse must be considered with R.O.M,so immidiate vaginal exam and F.H.R monitoring for 5-10 minutes is recommended L ABOR MANAGEMENT 3

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ANALGESIA AND ANESTHESIA The second stage is significantly prolong Pudendal block for episiotomy and intravaginal manipulation, Nitrous oxide plus oxygen provide further relief pain If general anesthesia is required,it can be induced with thiopental plus a muscle relaxant

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MORBIDITY AND MORTALITY 2 Fetal injuries: Fracture of humerus and clavicle, hematomas of s.c.m, separation of the epiphyses of scapula, femur or humerus. paralysis of arm (due to pressure on the brachial plexus or overstretching the neck), spoon shape or actual fracture skull, testicular injury.

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Fracture of femur

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VERSION A procedure in which the fetal presentation is altered by physical manipulation External cephalic version with %35-%80 success rate Internal podalic version for delivery second twin

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E XTERNAL CEPHALIC VERSION

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I NDICATIONS FOR EXTERNAL CEPHALIC VERSION 1 Breech presentation with 36 weeks of gestation and not in labor Version should not be done if N.V.D is contraindicated (previa, nonreassuring fetal status or uterine incision)

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I NDICATIONS FOR EXTERNAL CEPHALIC VERSION 2 Version is succesful in multiparous women with non engaged fetus and normal A.F Factors associated with failed version are diminished A.F, maternal obesity, anterior placenta, cervical dilatation, ant. or post. fetal spine and descent breech in to the pelvis

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TECHNIQUE OF VERSION 1 Should be done in an area that has ready access to perform emergency cesarean Sonography (A.F,previa,fetal anomalies) Fetal monitoring Tocolysis and epidural analgesia RH immunization Forward roll /backwardroll

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TECHNIQUE OF VERSION 2 Version is discontinued if exessive discomfort, persistant abnormal F.H.R or after multiple attempts The N.S.T is repeated after version until a normal test is obtained. Complications: abruption, fetal distress, fetal demise, uterine rupture, fetomaternal hemorrhage, amniotic fluid embolism, isoimmunization, preterm labor.

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MECHANISM OF LABOR 2 Version may be attempted before labor Management of labor (cesarean with classic incision) If the fetus is small (below 800 gr) and the pelvis is large spontaneous labor is possible (conduplicato corpore)

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V ERTEX SINCIPUT BROW FACE

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FACE PRESENTATION 1 The head is hyperextend so that occiput is in contact with the fetal back and mentum is presenting (Mentum ant. %60 Or Mentum post %25) Incidence:1/600 or %0.17 Labor usually impeded in term fetus with M.P

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M ANAGEMENT OF LABOR In the absence of a contracted pelvis and with effective labor Mentum Ant. succesful vaginal delivery usually will follow. First stage is similar to vertex. second stage is similar or slightly longer Oxytocin is not a cotraindication

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FACE PRESENTATION

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MENTUM POSTERIOR- MENTUM ANTERIOR

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BROW PRESENTATION 1 The rarest presentation The engaging diameter is mentoparietal (1.5 cm longer than vertex) Dianose: The frontal suture, large anterior fontanel, orbital ridge, eyes and the root of the nose can be felt on vaginal exam

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BROW PRESENTATION 2 Etiology: The causes are same as for the face presentation LABOR: Brow presentation is unstable and often converts to face (%30) or occiput (%20) and prognosis for delivery depends on the ultimate presentation

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POSTERIOR BROW

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COMPOUND PRESENTATION In compound presentation, an exteremity prolapses alongside the presenting part, with both presenting in the pelvis simultaneously. Incidence:1/700 (hand or arm prolapsed alongside the head)

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COMPOUND PRESENTATION Etiology: causes are conditions that prevent complete occlusion of the pelvic inlet by the fetal head like preterm birth Prognosis: perinatal loss is increased due to preterm delivery, cord prolapse and traumatic obstetrical prodcedure Management: In most cases, the prolapsed part will not interfere with labor

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COMPOUND PRESENTATION

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PERSISTANT OCCIPUT POSTERIOR 1 Most often undergo spontaneous anterior rotation Incidence: %15 early in labor and %5 at delivery Etiology: unknown, but transverse narrowing of the midpelvis is a contributing factor

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UMBLICAL CORD COMPLICATION The mean length of umbilical cord at term cm (35-80cm) The longest umbilical cord reported (129cm) Male fetus have larger cord (1.6cm at term) Vertex fetuses have cord 4.5cm longer than breech There is no correlation between cord length and either fetal or placental weight.

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CORD PROLAPSE 1 Incidence: %0.2-%0.6 (%0.4 in normal cord and never occurs with cords shorter than 35 cm and %4-%6 with cords longer than 80cm)

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CORD PROLAPSE 3 Diagnose: should be suspected in any F.H.R abnormalities after rupture of the membranes and confirmed by palpation the cord alongside the presenting part Management: Trendelenburg or knee chest position and presenting part manually elevated through vaginal exam and cesarean as soon as possible Perinatal mortality is almost %15

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TRUE KNOTS Incidence: %1(%0.3-%2.1), in longer cord is more common (%3 in cord longer than 80cm) Diagnose: Only after delivery Tight knot will demonstrate variable deceleration and must be manage No differnce in 5-minute Apgar scores or neurologic abnormalities at 1 year %4-%5 stillborns have through knots compared with %1 live-born infants

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NUCHAL CORD Incidence: %25 One loop %21 and two or more loops %4 %0.1 four or more loops %14 with short cords and %53 in long cords No evidence that nuchal cord cause fetal death or significant fetal distress No increase in the incidence of depressed 5- minute Apgar score, perinatal mortality or abnormal neonatal development.